NCC242572_FRO Submitted_20240823

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
T� r� EROSION & SEDIMENTATION CONTROL
Il` v "J No person may initiate any land-disturbing activity on one or more acres, 1/2 acre or more inside a
C. o UN r v N C watershed, as covered by the Sedimentation Pollution Control Act and the Iredell County Land
Development Code, before an acceptable erosion and sedimentation control plan has been submitted
and approved by the Iredell County Planning&Development, Erosion Control Section.
(Please type or print.)
Part A.
1. Project Name Davidson College Library Annex
2. Location of land-disturbing activity: County Iredell City or Township N/A
Highway/Street Dunmurry Road Latitude 35.511284 Longitude -80.836405
3. Approximate date land-disturbing activity will commence: September 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas). 6.0 AC
6. Amount of fee enclosed: $ $1,650 An application fee of$275.00 per acre(rounded up to the next acre) is
assessed without a ceiling amount (Example: a 8.10-acre application fee is $2475). For projects > than 0.5 acres but no
greater than 0.99 acres in a water supply watershed, a flat fee of$100.00 is assessed.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Teera Games E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners)
Trustees of Davidson College [phone]
Name Telephone Fax Number
P.O. Box 5000 209 Ridge Road
Current Mailing Address Current Street Address
Davidson NC 28035 Davidson NC 28035
City State Zip City State Zip
10. Deed Book No. 305 Page No. 133 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a comprehensive list of all
responsible parties on an attached sheet):
Trustees of Davidson College [e-mail]
Name E-mail Address
P.O. Box 5000 209 Ridge Road
Current Mailing Address Current Street Address
Davidson NC 28035 Davidson NC 28035
City State Zip City State Zip
Telephone [phone] Fax Number
Page 1 of 2

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the designated
North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone _ Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an assumed name, attach
a copy of the Certificate of Assumed Name. If the Financially Responsible Party is a Corporation, give name and street
address of the Registered Agent:
David Holthouser [e-mail]
Name of Registered Agent E-mail Address
P.O. Box 5000 209 Ridge Road
Current Mailing Address Current Street Address
Davidson NC 28035 Davidson NC 28035
City State Zip City State Zip
Telephone [phone] Fax Number
The above information is true and correct to the best of my knowledge and belief and was provided by me under oath (This form
must be signed by the Financially Responsible Person if an individual or his attorney-in-fact, or if not an individual, by an officer,
director, partner, or registered agent with the authority to execute instruments for the Financially Responsible Person). I agree to
provide corrected information should there by any change in the information provided herein.
David Holthouser Director of Facilities and Engineering
Type or print name Title or Authority
07/17/2024
Signature Date
I, I✓Y1A6— r 'f ►L31�c2._ , a Notary Public of the County of M tL G' ��j
State of North Carolina, hereby certify that ThvE"" }IV 1 � 4U- (- appeared]personally before me this day
and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal,this h day of LA- \ ,20 ,I
��►0, OQ fig. Notary
Seal r, t�" a
,zd 0. My commission expires ` �� _� ��
r Z
.. 5'Z��t S
y ��
a 4.` •.•...• 4
Page 2 of 2